MUSC GME Resident Handbook

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Resident Handbook Introduction

Letter of Committment/
Accreditation Status Disclaimer

Administration & Governance - Graduate Medical Education Programs

Policies & Procedures

Salaries & Benefits

MUSC Policies

Appendix 1 - Resident Agreements (Medical and Dental)

Appendix 2 - Evaluation Forms

Appendix 3 - Forms

Appendix 4 - Off-Cycle Residents

Appendix 5 - Scopes of Practice

COMPLIANCE AND CODE OF CONDUCT
(For more info see Medical Center Policy A-67)

PURPOSE

To establish a policy which underscores the commitment of MUSC to comply fully with applicable laws, government regulations, and MUSC policies.

POLICY

It is the policy of MUSC to adhere to the highest legal and ethical standards in its business activities and to ensure compliance with all applicable laws. The Medical Center shall demonstrate its commitment through the establishment of a code of conduct and a comprehensive compliance program.

INFORMATION AND PROCEDURE

A.   Compliance Officer(s) and Committee

1. The Vice President for Clinical Operations and Executive Director, Medical Center, shall appoint a Chief Compliance Officer and committee to oversee development and monitoring of a Medical Center-wide compliance program.
   
   
2. The compliance committee shall: assess compliance related issues; provide support or guidelines to service areas for development of area-specific procedures; provide support for educational programs; disseminate compliance  related information; receive, evaluate and respond to reports of potential violations; and, recommend or otherwise ensure corrective measures are taken when necessary.
   
   
3. The Chief Compliance Officer provides the Administrator of Finance with relevant reports and information concerning violations. The MUSC President and   Board of Trustees will be updated on a regular basis.
   

B. Code of Conduct

1. Obey The Law
   
   MUSC is committed to conducting its services lawfully and ethically. It is critical that all employees meet the highest standards of conduct  through strict observance of all laws and regulatory requirements. As a condition of employment, all employees are expected to comply with applicable laws and regulations. Unfamiliarity with relevant laws and regulations is no excuse for violations.
   
   Employees can learn the laws and regulations by asking supervisors when assistance is needed in understanding how the various laws and regulations apply to performance of duties. Employees are also expected to be informed on various laws and regulations through participating in training programs, reading MUSC policies, keeping abreast of Medical Center newsletters, through taking the initiative for self-development and by contacting the Medical Center Compliance Office.
   
   
2. Keep Accurate Records
   
   Every employee is expected to comply with MUSC and government requirements regarding record keeping. All records must be prepared  accurately and retained in accordance with requirements.
   
   
3. Report Information Truthfully
   
   All communication within MUSC or to outside organizations must be truthful.
   
   
4. Behave Ethically
   
   a. Every employee is expected to adhere to high ethical standards in performing duties. Employees must comply with MUSC's Code of Ethical Behavior policy.
   
   b. Every employee is expected to avoid any situation which could be viewed as a conflict of interest in which the employee’s position is used for personal gain.
   
   
5. Confidentiality
   
   Every employee is expected to comply with MUSC's policy regarding patient confidentiality. Each employee must sign a statement indicating familiarity with the policy.
   
   
6. Report Possible Violations
   
   
   a. Every employee is expected to report any activity that he or she reasonably believes is in violation of the law or MUSC policies. The employee need not be certain that a violation has occurred to report it. Reporting enables MUSC to investigate and resolve matters promptly.
   
   b. Reports may be made by an employee to his or her supervisor or to the Medical Center Compliance Office through campus mail (Room 205 MUH), E-mail (COMPLIANCE), telephone hotline or, in person to a Compliance Officer. Anonymous reports may be made, however, such reports tend to be more difficult to investigate.
   
   c. Reports of violations by employees may be made without fear of retribution.
   

C. Compliance With Applicable Laws and Areas of Special Concern

1. All employees must follow laws and regulations which relate to their duties. Examples of violations include, but are not limited to: intentional deception or misrepresentation, practices which result in unnecessary costs or improper payments, improper claims to any Federal or non-Federal entity, billing irregularities, waste, fraud, patient abuse, misuse of controlled substances, bribes, kickbacks, false statements, money laundering, obstruction of investigations, embezzlement, theft, unlawful employment practices and others.
   
2. Medical Center service areas with responsibilities covering areas of special emphasis are responsible for preparing an area specific plan and training program where appropriate.
   
   Examples of areas or programs of special emphasis include: admissions
   procedures, patient rights, referrals, billing, use of business information, conflict
   of interest, advertising and marketing, employment, government investigations,
   document retention and others.
   

D. Education and Communication

1. The Compliance policy and program are routinely communicated to all employees through the employee orientation, Medical Center newsletter, departmental  meetings and other methods of communication.
   
   
2. The Medical Center Compliance Office will ensure that training is provided to managers throughout the Medical Center at least annually where appropriate. Management Training will be documented.
   
   
3. Managers are expected to inform employees of the compliance program and include compliance in the competency assessment process and/or performance appraisal.
   
   
4. The compliance program includes an internal mechanism for reporting potential violations and a disciplinary plan for compliance violators.
   
   
5. Employees who report violations are assured they may do so without fear of retribution.
   
   
6. The exit process includes an opportunity for employees to report any possible violations of law or MUSC policy.
   

E. Auditing and Monitoring

1. All service areas are required to assess compliance issues and as appropriate develop a systematic process to monitor and take corrective measures.
   
   
2. An internal response mechanism is available for any employee to report a potential violation. This includes a campus mailbox (205 MUH), E-mail (COMPLIANCE), telephone hotline and opportunities to report to the immediate supervisor or a compliance officer. The Chief Compliance Officer reviews and evaluates all allegations and consults with the compliance committee when appropriate, maintains a record of the potential violations and takes corrective measures as needed.
   
   
3. Periodic audits by internal and external sources will target selected areas throughout the Medical Center to ensure compliance and to determine if proper controls are in place. Audit findings will be reviewed by the compliance committee.